A Menu of Change

Coping with Labor

The Joint Commission requires appropriate assessment and management of pain in hospitalized patients, however it does not dictate which assessment tools or pain management methods should be used.1 Maternity care professionals may struggle to support the full range of comfort and pain relief options in settings where pain assessment tools designed for non-maternity patients are used.2 Use of assessment tools and pain management approaches specific to labor pain have helped some settings better meet women’s expectations and needs for comfort in labor.2

Pharmacologic vs. Non-Pharmacologic Options

According to the Listening to Mothers III survey 67 percent of laboring women chose to address the pain of labor with epidural analgesia or spinal anesthesia.3 While these types of pain management techniques are effective in reducing pain, they dramatically alter the physiology and management of labor and birth and may be accompanied by adverse maternal and fetal/newborn effects. Difficulty voiding, hypotension, fever and an increased duration of second stage of labor are maternal effects associated with epidurals.4 Fever may lead to sepsis workups, antibiotic administration, or both for the newborn. Epidural analgesia is also associated with additional interventions during labor such as continuous fetal monitoring, bladder catheterization, augmentation of labor, vacuum extraction, forceps delivery, and episiotomy.4,5

Non-pharmacologic methods for promoting comfort, also called labor support, can be administered to the laboring women by friends and family, a doula, the intrapartum nurse, the midwife and the physician. Labor support has been defined as the intentional human interaction between the provider and the laboring woman that assists in positive coping methods during the labor and birth process.6 Four categories of labor support have been defined by various researchers. These include: physical, emotional, instructional/informational, and advocacy.7

Categories of Labor Support

Physical support encompasses maternal positioning, the use of touch, application of cold and heat and control of the environment (light, temperature, etc.).

Emotional support includes presenting a caring attitude, the use of distraction, being present with the laboring woman and the use of humor and spirituality as appropriate.

Instructional/informational support includes providing assistance with relaxation and breathing and using effective communication techniques.

Advocacy labor support includes conveying respect, building trust, providing security and giving laboring women control throughout the birth process.

Continuous labor support has been found to be associated with positive birth outcomes such as an increased incidence of spontaneous vaginal birth; fewer incidences of analgesia use in labor; shorter labors; higher ratings of maternal satisfaction; fewer operative births; and higher five-minute Apgar scores.8 Simkin & O’Hara9 also found upright positions increase maternal comfort; touch provided by a nurse relieves pain, reduces anxiety and enhances labor progress; and back pain is reduced through the use of intradermal sterile water injections. No studies have reported harms associated with these techniques.

Role of Birth Environment in Promoting Comfort

Coping and comfort of the laboring woman can be facilitated by enhancing positive or comforting characteristics of the birth environment10 such as policies that promote ambulation in labor; equipment available to encourage alternative position, such as birth balls, squatting bars or rebozos; and the placement of furniture and philosophy of care that guides the unit. Providers of labor support must have adequate education, knowledge, competence, skill and confidence in supporting normal labor through the use of comfort and coping techniques or labor support.7,11 Those who assist women throughout labor must have a commitment to working with women through education to enhance their confidence and diminish fear as well as commitment to shared decision making.

Challenges to Labor Support

Barriers to the use of labor support practices include inductions of labor, frequent use of epidurals, continuous fetal monitoring, policies that restrict ambulation, maternal positioning and oral intake during labor and nursing staff comfort level with the necessary skills to support women using non-pharmacologic approaches to pain relief. When the unit culture does not place a high value on physiologic birth or labor support, this can interfere with achieving the positive outcomes associated with techniques of coping and comfort.12,13